Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department

Socioeconomic disparities and trends in the utilization of regional and neuraxial anesthesia for pediatric femur fracture repair

Pediatric femur fractures often necessitate surgical intervention, with pain management being critical for both immediate and long-term outcomes. Peripheral nerve blocks (PNBs) and neuraxial techniques are effective in providing targeted pain relief while minimizing systemic opioid exposure. Despite their benefits, the utilization of these anesthesia techniques in pediatric orthopedic surgeries is limited, particularly among socioeconomically disadvantaged patients. This study aims to evaluate the association between socioeconomic status (SES) and the use of regional and neuraxial anesthesia in pediatric femur fracture repairs, focusing on healthcare resource utilization (HRU) outcomes such as hospital length of stay (LOS), total hospital charges, and discharge disposition. Using the 2016-2020 NIS database, we identified 43,605 pediatric patients who underwent femur fracture repair. Only 1 % received PNB, and 0.1 % received spinal block (SB). Our analysis revealed that PNB was less likely to be administered to patients from lower SES backgrounds, those with subtrochanteric fractures, or those requiring delayed repair. Conversely, PNB was associated with reduced HRU, while SB was linked to increased HRU. The findings underscore significant disparities in the application of regional anesthesia, influenced by socioeconomic factors. Our study highlights the need for standardized guidelines and interventions to address these disparities, ensuring equitable access to effective pain management techniques in pediatric orthopedic care. Further research is warranted to understand the barriers to the utilization of PNB and to develop strategies to enhance its adoption, particularly among underserved populations.

Building Blocks-A Block-by-Block Approach to Better Emergency Care in Children

OBJECTIVE

We describe a case series of regional nerve blocks, which comprise an adapted framework for the pediatric emergency setting and were performed by pediatric emergency medicine physicians.

METHODS

A case series of 8 different ultrasound-guided nerve blocks and 1 anatomical block, performed in 11 pediatric patients, aged 7 weeks to 17 years.

RESULTS

All blocks resulted in adequate analgesia. No procedural complications were observed.

CONCLUSION

We describe a set of nerve blocks performed by emergency medicine physicians in the pediatric population in an ED setting. In suitable settings, this is a safe and effective tool for procedural analgesia or for pain management. In such cases, performing an ultrasound-guided nerve block in the ED is a viable alternative for repeated doses of opiates, deep procedural sedation, or the operating theater. We propose this set of regional anesthesia procedures as a pediatric-adapted toolkit for the emergency physician to be performed in children in the ED setting. Adopting this set of procedures ensures better and safer care for children and provides a training framework for pediatric ED physicians.

Updates in pediatric ultrasound

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) has various diagnostic and therapeutic applications in the pediatric acute care setting that have an impact on clinical outcomes.

RECENT FINDINGS

POCUS can improve diagnostic efficiency and expedite management in pediatric patients who present to the emergency department with common complaints such as respiratory distress, abdominal pain, shock, and pain.

SUMMARY

Rapid advancements in POCUS have allowed it to become a powerful tool in pediatric care. As the clinical applications of ultrasound diversify, research is needed to evaluate impacts on healthcare outcomes, delivery, and costs.

Ultrasound-Guided Paravenous Saphenous Nerve Block for Lower Extremity Abscess Incision and Drainage in a Male Adolescent

ABSTRACT

The use of ultrasound-guided regional anesthesia is growing as a modality for analgesia provision within the pediatric emergency department. We present a case in which a paravenous saphenous nerve block was used for anesthesia during incision and drainage of a lower extremity abscess. We further review the technique and literature concerning this straightforward and effective procedure.

Regional anesthesia in trauma patients: a quality improvement study

BACKGROUND

Traumatic injury is associated with severe pain that is often inadequately managed. Opioids remain the mainstay of pain management in this population because of their ease of use. However, opioids have significant side effects including nausea, delirium, and respiratory depression. Regional anesthesia has been demonstrated in the perioperative setting to provide superior analgesia with fewer side effects and a reduced length of stay. Similarly, regional anesthesia has been shown to improve morbidity for extremity fractures and dislocations when introduced early.

METHODS

This was a prospective cohort quality improvement study evaluating the use of earlier and more consistent regional anesthesia procedures in 28 consecutive trauma patients at a large Canadian trauma center. In this quasi-experimental before and after study, we identified all trauma patients with an ISS < 15 that would have been candidates for a peripheral nerve block and compared them to the study population that received a regional anesthesia nerve block within 24 h of admission.

RESULTS

The introduction of a multidisciplinary pain program into our level 1 regional trauma center resulted in a decrease in pain severity and opioid consumption of 55% and 61%, respectively, after 24 h of admission. Length of stay in the emergency department decreased (11.5 ± 6.9 vs. 4.9 ± 4.4 h; p < 0.01) while hospital length of stay did not (338 ± 276 vs. 285 ± 205 h; p = 0.4).

CONCLUSION

This quality improvement proof-of-principle study reveals the potential advantages for regional anesthesia, such as decreased emergency department use, opioid consumption, and pain severity. Further randomized trials are necessary, however, to describe a direct benefit from peripheral nerve blockade on reducing length of stay for trauma patients.

Ultrasound-Guided Regional Anesthesia of the Femoral Nerve in the Pediatric Emergency Department

OBJECTIVES

Femur fractures are painful, and use of systemic opioids and other sedatives can be dangerous in pediatric patients. The fascia iliaca compartment nerve block and femoral nerve block are regional anesthesia techniques to provide analgesia by anesthetizing the femoral nerve. They are widely used in adult patients and are associated with good effect and reduced opioid use. Ultrasound (US) guidance of nerve blocks can increase their safety and efficacy. We sought to report on the use and safety of US-guided regional anesthesia of the femoral nerve performed by emergency physicians for femur fractures in 6 pediatric emergency departments.

METHODS

Records were queried at 6 pediatric EDs across North America to identify patients with femur fractures managed with US-guided regional anesthesia of the femoral nerve between January 1, 2016, and May 1, 2021. Data were abstracted regarding demographics, injury pattern, nerve block technique, and analgesic use before and after nerve block.

RESULTS

Eighty-five cases were identified. Median age was 5 years (interquartile range, 2-9 years). Most patients were male and had sustained blunt trauma (59% low-mechanism falls). Ninety-four percent of injuries were managed operatively. Most patients (79%) received intravenous opioid analgesia before their nerve block. Ropivacaine was the most common local anesthetic used (69% of blocks). No procedural complications or adverse effects were identified.

CONCLUSIONS

Ultrasound-guided regional anesthesia of the femoral nerve is widely performed and can be performed safely on pediatric patients by emergency physicians and trainees in the pediatric emergency department.

Ultrasound-Guided Supraclavicular Brachial Plexus Blocks Performed by Pediatric Emergency Medicine Physicians for Painful Orthopedic Procedures in a Pediatric Emergency Department-A Case Series

OBJECTIVE

The aim of this study was to describe our experience with ultrasound-guided supraclavicular brachial plexus blocks performed by pediatric emergency physicians for the purpose of forearm fracture reductions in the emergency department.

METHODS

We present a case series of 15 pediatric patients aged 7 to 17 years undergoing ultrasound-guided supraclavicular blocks.

RESULTS

All blocks resulted in adequate analgesia. No procedural complications were observed.

CONCLUSIONS

We conclude that in select pediatric cases ultrasound-guided brachial plexus blocks can be a safe, swift, and efficient means of pain management and procedural analgesia. This approach obviates the need for sedation, thus shortening the time lag between presentation and the reduction procedure, as well as overall length of stay.

Comparison Between Ultrasound-guided Caudal Analgesia versus Peripheral Nerve Blocks for Lower Limb Surgeries in Pediatrics: A Randomized Controlled Prospective Study

Background and Aim

Ultrasound (US) guided regional analgesia is a safe and effective method in providing perioperative analgesia in pediatrics with a high success rate rapid onset and fewer side effects. The aim of this study was to compare the efficacy of US-guided caudal block versus US-guided peripheral nerve blocks (femoral and sciatic nerve blocks) in providing perioperative analgesia in pediatrics undergoing unilateral lower limb surgery.

Methods

Children aged 1–12 years scheduled for unilateral lower limb surgery during the period from January 2020 to December 2021 were randomly allocated into two groups. Group C where pediatrics received US-guided caudal block, while in group P, pediatrics received US-guided femoral and sciatic nerve blocks after the induction of general anesthesia (GA). The primary aim was to compare the postoperative pain (evaluated by the COMFORT pain score) between the two groups. Secondary aims were to compare perioperative opioids used parents’ satisfaction and occurrence of side effects.

Results

Pediatrics who underwent unilateral lower limb surgeries were allocated into two groups (group C and group P). There was no significant difference between patients’ baseline characteristics and the postoperative pain score at 2, 4, 16, and 20 h.’ However there was a statistical significance at 6, 8, 12, and 24 h postoperatively, frequency of analgesia as well as the total postoperative dose of opiates (nalbuphine). Time to first analgesic (nalbuphine) requirement was significantly less in group C with a mean of (9.6±2.9 h) than in group P with a mean of (15.1±3.5 h). Parents of children in group P were more satisfied than those in group C with no recorded complications for both techniques.

Conclusion

US-guided lower limb peripheral nerve block is a simple and safe method to provide adequate and more prolonged analgesia compared to US-guided caudal block for lower limb surgeries in pediatrics.

Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department

OBJECTIVES

We aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED).

METHODS

This retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB.

RESULTS

Of 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%-70%). Overall, 21 children (15%) required a second analgesic after the FINB.

CONCLUSION

The routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

Ultrasound-Guided Posterior Tibial Nerve Block for Plantar Foot Foreign Body Removal

Ultrasound-guided regional anesthesia is a growing modality within the pediatric emergency department. Here we present a case where a posterior tibial nerve block was used for anesthesia during foreign body removal from the plantar foot. We further review the technique and literature regarding this straightforward and highly effective procedure.

Getting started in paediatric emergency medicine point-of-care ultrasound: Five fundamental applications

Point-of-care ultrasound is a valuable tool in the Paediatric Emergency Medicine department. It can be utilised at the patient bedside to augment the physical examination, improving clinical accuracy. Alternatively, it can safeguard needle guided procedures and improve their success rate. It allows real-time information to be gathered without exposing the child to ionising radiation. This article outlines five fundamental applications and how it can be incorporated into clinical practice.

Newer nerve blocks in pediatric surgery

PURPOSE OF THE REVIEW

The purpose of this manuscript is to provide a brief discussion of the current direction in pediatric regional anesthesia, highlighting both newer nerve blocks and techniques and traditional nerve blocks.

RECENT FINDINGS

The number of nerve blocks performed in pediatric patients continues to increase. This growth is likely related in part to the recent focus on perioperative multimodal analgesia, in addition to growing data demonstrating safety and efficacy in this patient population. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated lack of major complications and general overall safety with pediatric nerve blocks. The growing prevalence of ultrasound-guided regional anesthesia has not only improved the safety profile, but also increased the efficacy of both peripheral nerve blocks and perineural catheters.

SUMMARY

As the push for multimodal analgesia increases and the breadth of pediatric regional anesthesia continues to expand, further large prospective studies will be needed to demonstrate continued efficacy and overall safety.

Ultrasound-Guided Popliteal Sciatic Nerve Block for an Ankle Laceration in a Pediatric Emergency Department

Although ultrasound-guided peripheral nerve block has recently been introduced into pediatric emergency departments, knowledge of its use is limited. We present here a case demonstrating the safety and effectiveness of ultrasound-guided popliteal sciatic nerve block for a pediatric spoke injury in a pediatric emergency department setting.

A prospective, double-blinded, randomized comparison of ultrasound-guided femoral nerve block with lateral femoral cutaneous nerve block versus standard anesthetic management for pain control during and after traumatic femur fracture repair in the pediatric population

Background

Traumatic injury of the femur resulting in femoral fracture may result in significant postoperative pain. As with other causes of acute pain, regional anesthesia may offer a benefit over conventional therapy with intravenous opioids. This study prospectively assesses the effects of femoral nerve blockade with a lateral femoral cutaneous nerve block (FN-LFCN) on intraoperative anesthetic requirements, postoperative pain scores, and opioid requirements.

Materials and methods

Seventeen pediatric patients (age 2–18 years) undergoing surgical repair of a traumatic femur fracture fulfilled the study criteria and were randomly assigned to general anesthesia with either an FN-LFCN block (n = 10) or intravenous opioids (n = 7). All patients received a general anesthetic with isoflurane for maintenance anesthesia during the surgical repair of the femur fracture. Patients randomized to the FN-LFCN block group received ultrasound-guided nerve blockade using ropivacaine (0.2%/0.5% based on patient weight). At the conclusion of surgery, the airway device was removed once tracheal extubation criteria were achieved, and patients were transported to the post-anesthesia care unit (PACU) for recovery and assessment of pain by a blinded study nurse.

Results

The final study cohort included 17 patients (n = 10 for FN-LFCN block group; n = 7 for the intravenous opioid group). Although the median of the maximum postoperative pain scores in the regional group was 0, this did not reach statistical significance when compared to the median pain score of 3 in the intravenous opioid group. Likewise, no difference between the two groups was noted when comparing intraoperative anesthetic requirements, opioid requirements (intraoperative, in the post-anesthesia recovery room, and in the inpatient ward), and the time to first opioid requirement postoperatively in the inpatient ward.

Conclusion

This prospective, randomized, double-blinded study failed to demonstrate a clear benefit of regional anesthesia over intravenous opioids intraoperatively and postoperatively during repair of femoral shaft fractures in the pediatric population.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Management of acute pediatric pain in the emergency department

PURPOSE OF REVIEW

This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic.

RECENT FINDINGS

Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow.

SUMMARY

The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.

Point-of-care ultrasound in paediatric emergency medicine

Point-of-care ultrasound (POC US) is an adjunct to clinical paediatric emergency medicine practice that is rapidly evolving, improving the outcomes of procedural techniques such as vascular access, nerve blocks and fluid aspiration and showing the potential to fast-track diagnostic streaming in a range of presenting complaints and conditions, from shock and respiratory distress to skeletal trauma. This article reviews the procedural and diagnostic uses, both established and emerging, and provides an overview of the necessary components of quality assurance during this introductory phase.

Ultrasound-Guided Femoral Nerve Blocks

Pediatric acute femur fractures are a relatively common major orthopedic injury seen in emergency departments. Providing adequate and safe analgesia is essential while patients await definitive management of these fractures. Opioid medications are typically used to treat fracture-associated pain but have well-known adverse effects including respiratory and central nervous system depression, pruritus, nausea, and allergic reactions. Dose titration of opioids in pediatric patients may be difficult and requires frequent nursing and physician reassessments. Regional anesthesia using ultrasound guidance has been proposed as a reliable and safe method to provide pain relief for this population and to decrease reliance on opioid medications. There is a growing body of literature on the utility and safety of ultrasound-guided femoral nerve blocks for pediatric patients in the acute care setting. This review article covers recent literature on point-of-care ultrasound-guided femoral nerve blocks for pediatric patients, with a discussion of the indications, sonographic anatomy, selection of anesthetics, nerve block technique, and complications. This review supplements the expert supervision and practice required to gain competency.

Regional anesthesia for the trauma patient: improving patient outcomes

Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.